Severe pancreatico-duodenal injuries: the effectiveness of pyloric exclusion with vagotomy.

The operative management and clinical course of 17 patients treated for severe pancreatico-duodenal injuries from 1983 to 1990 was reviewed. The etiology of these injuries was gunshot wound in 15 patients; stab wound in 1 patient; and a motor vehicle accident in 1 patient. Seven patients presented in shock with a systolic blood pressure of less than 80. At exploration, 57 associated injuries were found in the 17 patients including 16 major vascular injuries. All patients were treated with pyloric exclusion and drainage. Vagotomy was performed in eight patients. None of these 17 patients were felt to have extensive enough damage to require pancreatico-duodenectomy. Two patients died in the immediate postoperative period of severe coagulopathy and two patients died of sepsis. Seven patients had complications related to the pancreatico-duodenal injury. All seven developed pancreatic fistulas; three also had pancreatitis and two developed multiple enterocutaneous fistulas. Systemic complications included pulmonary complications in eight patients and sepsis in five patients, including two patients with abdominal abscesses. Six patients bled in the immediate postoperative period secondary to coagulopathy. Three patients had complications related to pyloric exclusion. One developed afferent loop syndrome necessitating reoperation. The other two had marginal ulcers, which either perforated or bled and required reoperation. Of interest, neither of these two patients had vagotomy initially. The results of this series confirm the effectiveness of pyloric exclusion with vagotomy for severe pancreatico-duodenal injury.     

The therapy of anaphylactic shock

Anaphylaxis is an acute, often life-threatening systemic reaction to mediators released by basophils and mast cells. Histamine, leukotrienes, prostaglandins, and other mediators are responsible for complex and varied reactions in man. Serious cardiovascular or pulmonary involvement can lead to death within minutes. Therapy depends on prompt recognition of the disease and rapid administration of epinephrine. Even in ideal clinical settings, response to therapy may be slow and a long resuscitation necessary. Antihistamines, glucocorticoids, intravascular volume expansion, sympathomimetics, bronchodilators, and controlled ventilation all may be necessary. Taking careful allergy histories; using enteral routes for drug administration when possible; observing patients, who have received injections for at least 20 minutes; and rapidly treating patients with epinephrine are the main means of reducing the incidence and mortality of this disease.     

Metabolism during hepatic transplantation: indicators of allograft function

In an attempt to determine the initial function of hepatic allografts, several metabolic indicators of hepatic function were studied intraoperatively in 12 cases of hepatic transplantation. The operation was divided into three sampling periods: baseline, anhepatic, and reperfusion. During the baseline period plasma lactate levels rose at 2.6 mmol/L/hr and continued to rise at a similar rate during the anhepatic period. Baseline period total free plasma amino acid levels (TFPAA) rose at a moderate rate of 0.4 mmol/L/hr. During the anhepatic period TFPAA levels rose at a fivefold greater rate than during baseline (p less than 0.01). The ability of the hepatic allograft to reduce abnormal levels of TFPAA and lactate during the reperfusion period was associated with reduced morbidity in the first 48 hours after transplantation. Intraoperative clearance of accumulated TFPAA is currently the best means of assessing initial allograft function. Elevated preoperative total serum bilirubin levels were also associated with increased early morbidity in hepatic transplant recipients.     

Barriers to the construction of a valued social identity: a case study of Alzheimer's disease

This case study describes a person with mild-to-moderate stage Alzheimer's disease (AD) and examines the relationship between malignant positioning and the ability of a person with AD to gain the cooperation of healthy persons to construct a valued social identity. Findings reveal that malignant positioning limited the person with AD to the embarrassing social identity of dysfunctional patient; whereas, the absence of such positioning allowed the subject to gain the cooperation from others necessary to construct a valued social identity, as well as reduce embarrassment and experience greater sense of self-worth. Preliminary recommendations on reducing malignant positioning are provided. Further research is required to elucidate the degree to which the present findings may be generalized.     

DNA-dependent protein kinase activity is not required for immunoglobulin class switching

Class switch recombination (CSR), similar to V(D)J recombination, is thought to involve DNA double strand breaks and repair by the nonhomologous end-joining pathway. A key component of this pathway is DNA-dependent protein kinase (DNA-PK), consisting of a catalytic subunit (DNA-PKcs) and a DNA-binding heterodimer (Ku70/80). To test whether DNA-PKcs activity is essential for CSR, we examined whether IgM(+) B cells from scid mice with site-directed H and L chain transgenes were able to undergo CSR. Although B cells from these mice were shown to lack DNA-PKcs activity, they were able to switch from IgM to IgG or IgA with close to the same efficiency as B cells from control transgenic and nontransgenic scid/+ mice, heterozygous for the scid mutation. We conclude that CSR, unlike V(D)J recombination, can readily occur in the absence of DNA-PKcs activity. We suggest nonhomologous end joining may not be the (primary or only) mechanism used to repair DNA breaks during CSR.